Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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1 Introduction and Literature Review Despite steady improvement in the overall health of the U.S. population, racial and ethnic minorities, with few exceptions, experience higher rates of morbidity and mortality than non-minorities.
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30 UNEQUAL TREATMENT than white Americans. For example, relative to whites, African Americans and Hispanics are less likely to receive appropriate cardiac medication (e.g., thrombolytic therapy, aspirin and beta blockers)
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31 INTRODUCTION AND LITERATURE REVIEW of health insurance coverage that healthcare consumers purchase or are provided, as well as their level of education and other unmeasured aspects of socioeconomic status (e.g., assertiveness in seeking care) significantly affect the quality and intensity of healthcare that they receive, and are highly correlated with race and ethnicity.
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32 UNEQUAL TREATMENT defined by cultural heritage, sociodemographic characteristics, geogra phy (e.g., a state or a region) , or diagnosis.
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33 INTRODUCTION AND LITERATURE REVIEW Clinical Appropriateness and Need Patient Preferences Difference The Operation of Quality of Health Care Healthcare Systems and Non-Minority Legal and Regulatory Climate Disparity Discrimination: Minority Biases, Stereotyping, and Uncertainty FIGURE 1-1 Differences, disparities, and discrimination: Populations with equal access to healthcare. SOURCE: Gomes and McGuire, 2001.
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34 UNEQUAL TREATMENT BOX 1-1 Revised Standards for the Classification of Federal Data on Race and Ethnicity Categories for Race: American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America)
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35 INTRODUCTION AND LITERATURE REVIEW related factors from the quality of healthcare for minorities remains an artificial exercise, and that policy solutions must consider the historic and contemporary forces that contribute to differences in access to and quality of healthcare. THE RELATIONSHIP BETWEEN RACIAL AND ETHNIC DISPARITIES IN HEALTH STATUS AND HEALTHCARE The health gap between minority and non-minority Americans has persisted, and in some cases, has increased in recent years.
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36 UNEQUAL TREATMENT and use of healthcare services is needed to seriously address racial and ethnic disparities in health status.
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37 INTRODUCTION AND LITERATURE REVIEW diverse; while white Americans currently constitute 71% of the population, by the year 2050 nearly one in two Americans will be a person of color (U.S. Bureau of the Census, 2000)
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38 UNEQUAL TREATMENT challenges and barriers to high quality care, their experiences expose healthcare systems' greatest weaknesses and problems -- problems that any American may face in attempting to access healthcare. In this context, the extent to which minorities are well or poorly served provides an important indicator of the state of healthcare in the nation.
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39 INTRODUCTION AND LITERATURE REVIEW clinical guidelines. To the extent that these studies shed light on potential sources of disparities in care, they are summarized in this review.
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40 UNEQUAL TREATMENT BOX 1-2 Criteria for Literature Review To assess the evidence regarding racial and ethnic differences in health care, the committee conducted literature searches via PUBMED and MEDLINE databases to identify studies examining racial and ethnic differ ences in medical care for a variety of disease categories and clinical ser vices. Searches were performed using combinations of following keywords: • Race, racial, ethnicity, ethnic, minority/ies, groups, African Ameri can, Black, American Indian, Alaska Native, Native American, Asian, Pa cific Islander, Hispanic, Latino.
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41 INTRODUCTION AND LITERATURE REVIEW In addition, to ensure the comprehensiveness of the review, the com mittee examined the reference lists of major review papers that summarize this literature (e.g., Geiger, this volume; Kressin and Petersen, 2001; Bonham, 2001; Sheifer, Escarce, and Schulman, 2000; Mayberry, Mili, and Ofili, 2000; Ford and Cooper, 1995)
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42 UNEQUAL TREATMENT lar care. The most rigorous studies in this area assess both potential underuse and overuse of services and appropriateness of care using wellestablished clinical and diagnostic criteria.
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43 INTRODUCTION AND LITERATURE REVIEW might be less appropriate for specific clinical services. Second, administrative data provide little indication as to whether patients were presented with all clinical options, whether patients accepted or refused recommendations, or whether the physician did not recommend clinical procedures.
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44 UNEQUAL TREATMENT differences were apparent in public, private, teaching, non-teaching, and urban/suburban hospitals, as well as in hospitals where patients were referred to other facilities for revascularization procedures and those that offer such procedures in-house. Similarly, Weitzman et al.
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45 INTRODUCTION AND LITERATURE REVIEW however, Asian Americans did not differ from whites in the rates of cardiac procedures. African-American and Hispanic patients remained less likely than whites to receive angioplasty, and African Americans were less likely to receive CABG when hospital characteristics were controlled.
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46 UNEQUAL TREATMENT larization were significantly lower, however, among patients initially seen in hospitals that did not provide revascularization services (and therefore had to refer patients to other hospitals) than those treated in settings that did provide revascularization (59% to 76%, respectively)
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47 INTRODUCTION AND LITERATURE REVIEW contrast, Peterson et al.
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48 UNEQUAL TREATMENT above illustrate. This finding is confirmed in a study of cardiovascular care in the United Kingdom, which offers universal access and free care at the point of use.
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49 INTRODUCTION AND LITERATURE REVIEW were slightly less likely than whites to undergo reperfusion therapy. Further, Schneider et al.
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50 UNEQUAL TREATMENT Summary of Literature on Racial and Ethnic Disparities in Cardiovascular Care The literature reviewed above illustrates that racial and ethnic disparities in cardiovascular care are robust and consistent across a range of studies conducted in different geographic regions with diverse patient populations seen in a range of clinical settings. This literature does not, however, provide a clear account of the sources of these disparities; rather, these studies provide clues regarding the types of factors that are not likely to fully explain disparities in cardiovascular care.
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51 INTRODUCTION AND LITERATURE REVIEW entirely when appropriate confounding variables were included in multivariate analysis. In general, these findings are limited to studies of patients seen in universally accessible care settings, such as the U.S.
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52 UNEQUAL TREATMENT patient outcomes (e.g., survival) despite disparate rates of treatment should not be interpreted as demonstrating that disparities in the use of medical intervention are inconsequential.
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53 INTRODUCTION AND LITERATURE REVIEW Studies of racial disparities in cancer diagnosis and treatment are less clear and consistent than studies of cardiac care, in part because many studies rely on data that use crude or incomplete indicators of the type of treatment provided and/or do not control for co-morbid factors. Variations in the extent of disease among patients are rarely well controlled, and the com prehensiveness of treatment cannot be evaluated.
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54 UNEQUAL TREATMENT munity, and availability of physicians, internists, and gastroenterologists per 100,000 population to predict use of diagnostic procedures for colon cancer among all Medicare Part B transactions in the state of Michigan from 1986 to 1989. African Americans were more likely than whites to receive a barium enema only, were less likely to receive a combination of barium enema and sigmoidoscopy, and were less likely to undergo colonoscopy.
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55 INTRODUCTION AND LITERATURE REVIEW found in stage of disease, utilization of health services before diagnosis of breast cancer, or receipt of breast examination. However, AfricanAmerican patients were more likely to die than whites (30% vs.
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56 UNEQUAL TREATMENT tive to whites. Older age, low cognitive performance, and increased number of other medications were also associated with failure to receive any analgesic agent.
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57 INTRODUCTION AND LITERATURE REVIEW tion therapy among a sample of African-American and white male veterans diagnosed with esophageal cancer and treated at VA hospitals. The authors found that after controlling for a variety of patient demographic and clinical characteristics, African-American patients with esophageal adenocarcinoma were less likely to undergo surgery than whites, but had similar rates of chemotherapy and radiation therapy.
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58 UNEQUAL TREATMENT testing. Among those receiving noninvasive testing, African Americans were 54% as likely to receive cerebral angiography, and among those receiving angiography, the odds of African Americans receiving carotid endarterectomy was 0.27.
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59 INTRODUCTION AND LITERATURE REVIEW are considered. Garg, Diener-West, and Powe (2001)
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60 UNEQUAL TREATMENT nificantly less likely than white males to report wanting a transplant. This difference was not significant among female patients.
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61 INTRODUCTION AND LITERATURE REVIEW HIV/AIDS HIV infection continues to spread more rapidly among AfricanAmerican and Hispanic populations than any other racial/ethnic group in the United States. While federal programs have been expanded in recent years to increase the availability of antiretroviral therapies, especially among low-income and ethnic minority populations, minorities face greater barriers than whites to appropriate care.
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62 UNEQUAL TREATMENT whites, but only 48% of eligible blacks received antiretroviral therapy, and PCP prophylaxis was received by 82% of eligible whites and only 58% of eligible blacks. African-American patients were significantly less likely than whites to receive antiretroviral therapy or PCP prophylaxis.
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63 INTRODUCTION AND LITERATURE REVIEW seen by an asthma specialist. African Americans were also more likely to use oral corticosteroids and were less likely to be prescribed inhaled anticholinergic medications.
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64 UNEQUAL TREATMENT Diabetes African Americans, Hispanics, and Native Americans experience a 50%-100% higher burden of illness and mortality due to diabetes than white Americans, yet the disease appears to be more poorly managed among minority patients. In a study of nearly 1,400 Medicare beneficiaries with a diagnosis of diabetes, Chin, Zhang, and Merrell (1998)
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65 INTRODUCTION AND LITERATURE REVIEW Todd, Samaroo, and Hoffman (1993) , for example, found that among Hispanic and non-Hispanic white patients with long-bone fracture treated at the UCLA Medical Center emergency department, Hispanic patients were twice as likely as white patients to receive no pain medication, even after controlling for patient, injury, and physician characteristics.
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66 UNEQUAL TREATMENT other hand, prescribed higher doses to African Americans than whites and females than males. Among "patients" presenting with sinusitis, no overall differences were observed in physicians' decisions to treat patients with antibiotics, but white patients were prescribed a longer course of antibiotics and were prescribed refills more often than African-American patients.
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67 INTRODUCTION AND LITERATURE REVIEW many of which have been directed at low-income and uninsured women, racial and ethnic disparities have been found with modest consistency in a range of maternal and child health services.
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68 UNEQUAL TREATMENT Breast-feeding promotion narrowly missed significance with a trend toward more advice for white women. A significant interaction between race and marital status emerged, such that black single women were 1.4 times more likely than single white women to not receive advice on drug cessation, while there were no racial differences among married women.
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69 INTRODUCTION AND LITERATURE REVIEW health factors and numbers of physician visits did not change these relationships, and they remained after controlling for age, maternal education, insurance, poverty status, source of care, geographic location, health status, number of bed days, number of reduced activity days, and physician visits. Similarly, Zito et al.
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70 UNEQUAL TREATMENT ior. Communication and trust are particularly critical in treatment, the report notes, and differences in the cultural perspectives of the patient and clinician/healthcare system must be acknowledged and addressed (U.S.
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71 INTRODUCTION AND LITERATURE REVIEW or low option selected for insurance coverage) , and need factors (annual medical expenses, family's annual medical expenses, other family member receipt of inpatient psychiatric care, sum of outpatient mental heath visits by other family members)
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72 UNEQUAL TREATMENT In one such study, Ayanian et al.
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73 INTRODUCTION AND LITERATURE REVIEW elderly Medicare patients, as a function of medical conditions and disabilities, income, insurance status, regional and rural residence, whether unpaid caregivers provide in-home services, and sociodemographic characteristics (e.g., gender, education)
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74 UNEQUAL TREATMENT sessed rates of preventable hospitalizations among children, working-age adults, and the elderly, while adjusting for a range of sociodemographic (e.g., age, income, insurance status) , community-level (e.g., neighborhood characteristics, physicians, and hospital beds per capita)
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75 INTRODUCTION AND LITERATURE REVIEW Gaps in Existing Research While the research reviewed here points to significant variation in access to and use of services by race and ethnicity, several gaps exist that must be addressed to develop a more comprehensive understanding of racial and ethnic disparities in healthcare. The most significant gap in this research is the failure to identify mechanisms by which these disparities occur.
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76 UNEQUAL TREATMENT leaving open the question of whether care received was sufficient given the type and severity of disease. Finally, one of the most significant limitations of existing research is the failure to analyze differences in care beyond comparisons of AfricanAmerican and white patients.
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77 INTRODUCTION AND LITERATURE REVIEW income typically each account for only about one fifth, and never even as much as one half, of the disparities .
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78 UNEQUAL TREATMENT ance are controlled statistically or by study design, race and ethnicity remain as significant predictors of the quality of care. This disparity is best illustrated in studies of care among Medicare populations (Gornick et al., 1996)
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79 INTRODUCTION AND LITERATURE REVIEW chapter, research is urgently needed to assess the quality of care for these populations relative to the burden of illness. A few of the studies that find no racial and ethnic differences in care indicate that characteristics of health systems may serve an important role in mediating these disparities.
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